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I have had two therapy sessions with a 24-year-old woman who was hospitalized six months ago for suicidal ideation. She has been stable since then and wants to use therapy to understand what led to her suicidal thoughts. She has given me permission to talk with her psychiatrist and her parents with whom she lives, and she suggested I contact the hospital to get their report of her stay. I usually like to keep the therapy between me and the client, but in this case I think information from these other sources might help.

I agree that it might be necessary to expand beyond your client’s self report of history and symptoms in order to insure your client’s safety while she explores her past suicidal ideation. This question addresses the decisions inherent in conducting an initial assessment, which is discussed in Chapter 6 of my book. I’ll review whether and how to include information from other mental health providers, family members, and treatment records, after discussing the sources of information that come from your client sessions.

Therapy usually begins with a conversation between you and the client in which she tells you what difficulties are leading her to seek help. The initial phase of establishing a therapeutic alliance overlaps with doing an assessment of the client, so you develop a comprehensive picture of her life and circumstances that will guide your treatment approach. Your therapy sessions provide two sources of information about the client: her self-report and your observations. In the first two sessions, she has probably told you about her current concerns and symptoms, living circumstances, and relevant events from the past including her hospitalization. Whether you have been consciously aware of it or not, you are also observing her and noticing the nonverbal aspects of her presentation that are congruent or incongruent with her verbal presentation. Another aspect of the therapy sessions is the impact of the sessions on your own emotional state.

Client self-report and therapist observations are usually the primary source of assessment information, and sometimes are the only source. In this case, I would suggest expanding the client’s self-report by using one or more assessment measures. The Crpss-Cutting Symptoms Measure, contained in the Assessment section of the DSM- 5, is free and can be downloaded at https://www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/assessment-measures. Your agency may have other measures that are relevant to her presenting issues or you can find assessment tools at http://www.integration.samhsa.gov/clinical-practice/screening-tools. It may be useful to compare the client’s narrative report in session with her self report on an objective assessment measure. Your treatment approach will be different if her scores on objective measures indicate greater risk than she has reported to you in the first two sessions.

In terms of the other sources you mention, consulting with her psychiatrist seems essential so that you can develop a collaborative relationship as treatment providers. As your client explores the sources of her suicidal ideation, her symptoms may temporarily increase and her medication needs may change. The psychiatrist can also share the client’s treatment history and response, which you can compare with your client’s report. Talking with your client’s parents is more complicated and needs further evaluation. I recommend postponing that conversation until you know more about your client’s current relationship with her parents, past events in the family, and general family dynamics. Over time you will begin to make inferences about these issues as you hear more about her perspective on their interactions. I would begin this exploration by asking what she expects her parents would tell you and how she would feel about you hearing that from them.

Last, your client has suggested that you read the hospital record. This may contain useful historical and clinical information, so I would recommend requesting it. Be aware that it may be more difficult to obtain a hospital record than to talk with the psychiatrist, depending on the procedures in place there. The discharge summary is the most useful clinical document, so you can ask for that rather than for the full record which will include notes from each nursing shift during her stay that are less relevant to her current status.

Combining these sources of information will result in a comprehensive assessment, which is especially important in cases with elevated risk. Supplementing the therapy sessions with self-report measures, information from another provider, treatment records, and possibly family members will enable you to be clearer in your treatment approach. Your overall goal will be to respond to the client’s desire to understand her past suicidal ideation while helping her maintain physical and emotional safety. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

I work at an agency that requires us to give a diagnosis to each of our clients. I’ve gotten comfortable with this requirement and the diagnoses I give to my clients, but I’m concerned that someone will ask me about their diagnosis. I think the clients will feel upset about knowing that I have diagnosed them, so I dread the possibility of someone asking me about it.

One section of Chapter 5 of my book specifically reviews how to discuss diagnosis with your client, and the case example at the end of that chapter includes an illustration of a therapeutic conversation about diagnosis. I’ll summarize some of the important points here.

Your concern is common among clinicians, who associate diagnosis with the medical model and a lack of subjective understanding and empathy for the client. Agencies whose clients rely on third party funding generally require that all clients receive a diagnosis because of funder requirements. Your clients might not be able to get the treatment they need without third party payment and your documentation of a diagnosis that meets medical necessity guidelines, but it does raise a clinical dilemma.

A place to start with this dilemma is to review your diagnoses and confirm that they are accurate based on the clients’ report of symptoms and your observation of them in session. It sounds like you’ve done this with your clients, but your level of concern may decrease if you go through this review systematically. If any of your diagnoses don’t fit the client’s report or if symptoms have changed during the course of treatment, you can modify the original diagnosis to fit the current symptom picture.

In anticipating a conversation with your client, there are several things to keep in mind. One issue is to think about the meaning of diagnosis at this particular time in treatment. A client who raises a question about diagnosis in the second session probably has different reasons for wanting to discuss it than a client who raises the question after six months. When a client asks about diagnosis, you can explore the meaning by saying something like “I’m happy to talk with you about this, but I’m also curious about what goes into your question.” Starting with reassurance that you will answer the question makes it more likely that the client will be open in sharing her/his motivation. You can then discuss the diagnosis in a way that addresses the client’s concern. For example, if the client expresses worry that she/he is “crazy” you will answer differently than if the client wonders what the number means on the statement she/he received from the insurance provider.

A second issue to consider is the emotional response your client is likely to have to the specific diagnosis you have assigned. Approach this conversation in the same way you approach any topic in the therapy. It is best to say a few sentences initially, then ask the client for her/his reaction and be alert for nonverbal cues that provide additional information. If the client’s diagnosis is something that may be negatively charged for your client, consider prefacing disclosure of the diagnosis by a statement like “You may have some preconceptions about what this particular diagnosis means, so if it’s all right, I’d like to tell you why I have used this diagnosis for you.” Then summarize the aspects of the client’s report of symptoms and your observations that support the diagnosis. You can then ask the client if your summary seems accurate. After you and the client have agreed on the symptoms and issues, you can then say “In the field of psychotherapy, that combination of difficulties is described with the diagnosis of (the name of the disorder)” and pause for the client’s response. If the client is concerned about whether this diagnosis means she/he will be unable to improve or to achieve life goals, you can discuss the treatment approaches that you are using and express realistic optimism that the client’s symptoms can be managed effectively.

Probably the most important way to insure a productive and therapeutic conversation about diagnosis is to continue to reflect on your views of diagnosis and the stigma you may hold about diagnosis in general or about specific disorders. If you develop the skill to speak openly about diagnosis, your clients’ shame, self-judgment and suspicion will be minimized. My personal definition of diagnosis is that it is a standard, professional way of summarizing a broad range of information about the client’s present and past symptoms and experiences. For me, a diagnosis doesn’t reflect a feeling or judgment about the client and it doesn’t imply a prediction about the client’s overall capacity to lead a fulfilling life. Holding the meaning of diagnosis in this way enables me to respond to my clients’ questions with confidence that the conversation will not have a negative impact on our therapeutic relationship.

I hope these suggestions are helpful in having conversations about diagnosis with your therapy clients. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

My agency requires assigning a diagnosis after the first session, and this is very hard to do. How can I give a diagnosis to my client when I don’t have complete information about them?

This agency requirement is probably related to third party billing and the need to document the medical necessity of the services you are providing to the client. While this requirement ensures that your clients have access to the services they need, it can be frustrating as a clinician to assign a diagnosis when you haven’t had a chance to develop a comprehensive understanding of their symptoms. I will suggest a couple of strategies regarding the notation of the diagnosis itself that may alleviate your concern and then outline a three-step process for arriving at a diagnosis after the first session or after a more thorough assessment. My comments are based on using the DSM-5, and may need to be adapted if your agency is using the DSM-IV.

One strategy is to check with your supervisor or the billing manager about the use of diagnoses marked “Provisional” when you have incomplete information. If this is allowed by the third party, it is a way to acknowledge that your diagnosis is tentative. Situations in which a “provisional” diagnosis are appropriate are when you know a client meets most of the criteria but haven’t confirmed the full set of criteria required for the diagnosis or when the client reports a diagnosis given by another health care provider that you haven’t verified independently. Also ask about the use of “Other Specified” and “Unspecified” diagnoses when you have determined which category the client’s symptoms fit but don’t know whether they meet the criteria for a specific diagnosis within that category. These diagnoses are often useful when your information is incomplete, if they are acceptable to the third party.

A second aspect of diagnosis that may alleviate some of your concern is to view diagnosis as an ongoing process rather than a decision that is made once for the duration of the client’s treatment. The diagnosis you assign after the first session may not be the diagnosis that accurately reflects the client’s history and symptoms that emerge as you complete an assessment. This will be most likely if you have used “provisional,” “other specified,” or “unspecified” in your diagnosis, but there are other times when the client’s initial presentation differs from the impression you get after four to six more sessions. I also suggest reviewing the diagnosis every six months or whenever you update the treatment plan. This allows you to update the diagnosis if appropriate, to reflect changes in the client’s symptoms or new historical information you have learned.

I have developed a three-step process to help new clinicians develop a diagnosis, and the worksheet reflecting this process is available for download in an online workbook. I find that new clinicians often have difficulty prioritizing the different pieces of information they have about clients, and this leads to confusion in identifying the most accurate diagnosis. A more detailed description of the diagnostic process is contained in Chapter 5 of my book, available through Amazon or Routledge.

My recommendation is to begin by listing the client’s current symptoms and past symptoms reported as part of the history. This ensures that you consider all of the data that is relevant to the client’s diagnosis rather than prematurely focusing on one aspect of the presentation that may lead to an inaccurate diagnosis or may neglect a secondary diagnosis that is clinically important.

Second, make note of the categories in the DSM-5 that fit your client’s symptoms, being as comprehensive as possible. In the worksheet, I suggest that you note the categories in which symptoms are present (or are part of the history) and then note whether these symptoms are relevant to the current treatment, i.e., part of the reason for the client seeking treatment. This notation will serve as a reminder to address the relevant symptoms in your treatment goals. Remember to include the “Other Conditions” category if your client has psychosocial stressors, relationship difficulties, or a history of trauma.

The third step is to look at the specific diagnoses within the categories you have noted to see whether your client’s symptoms meet the criteria for one or more diagnoses. If you noted the “Other Conditions” category, review these codes to determine which situational factors are important to include in your diagnosis. Often, your client’s clinical presentation may be best described by one or more diagnoses and one or more Z codes. If this is the case, choose the diagnosis that best represents the reason for treatment as the primary diagnosis which will be reported for billing purposes. The other diagnoses will be included in your assessment to provide a comprehensive view of the client’s symptoms, history, and current psychosocial stressors.

I hope you find these comments helpful in working with DSM-5 and diagnosis. Please email me with comments, questions, or suggestions for future blog topics.

I am starting work at an agency that uses the DSM-V or 5 rather than the DSM-IV which I have been using at my previous agency. What should I know about the changes between the two versions?

The DSM-5 (it is “5” rather than “V”) was published in May 2013 but many agencies are not yet using it or are just beginning to transition to the new version. There are a number of structural changes in the organization of the DSM-5 and a number of revised or new diagnoses as well. The DSM-5 itself contains a summary of the changes in an appendix, which you may find helpful to review. In addition, I recommend that you look up the criteria for each diagnosis as you begin to use the DSM-5 to make sure you are applying it correctly. I have summarized the structural and diagnostic changes below.

Structural Changes

The DSM-5 no longer uses a five axis diagnostic system as has been true in DSM-III and DSM-IV. Instead of five axes, you list the mental health and substance use disorders that apply in the order of their clinical relevance to your treatment, followed by listing the client’s medical conditions. Many of the psychosocial stressors that were previously listed on Axis IV are contained in an expanded section of “other conditions” called V codes or Z codes so they are included in your diagnostic list. The GAF is no longer used, but several assessment measures are included in the DSM-5 as alternatives to the GAF for assessing the client’s level of functioning.

Some diagnoses are combined on a continuum with codes for severity rather than having different diagnoses corresponding to different levels of severity. Autism spectrum disorder and substance use disorders are two commonly used diagnoses that have been changed in this way. The DSM-5 calls this a dimensional approach to diagnosis rather than a categorical or binary approach. Instead of “alcohol abuse” and “alcohol dependence” disorders, DSM-5 uses “alcohol use disorder” with a code for severity based on the number of criteria met by the client’s use.

The organization of diagnostic categories has been revised so that the categories are more clearly differentiated from each other. For example, all disorders formerly in the category of “disorders usually first diagnosed in infancy, childhood or adolescence” have been moved to the category of the diagnosis itself (e.g., attention deficit hyperactivity disorder moved to neurodevelopmental disorders). In addition, some categories have been divided into two smaller categories (e.g., bipolar and depressive disorders, anxiety and obsessive-compulsive & related disorders) or have been combined differently (e.g., trauma & stressor related disorders).

The category of “Other Conditions” has been greatly expanded to cover some of the conditions previously listed on Axis IV as well as other historical and current situational circumstances that may be relevant to the current treatment.

Diagnostic Changes

There are a number of new diagnoses in the DSM-5 as well as revised criteria for other diagnoses. Below is a partial list of new diagnoses:

Disruptive mood dysregulation disorder (age of onset between 6 and 10 years of age)

Gambling disorder (previously listed as a condition for further study)

All disorders in the category of “somatic symptom and related disorders” (renamed from “somatoform disorders” in DSM-IV)

This is a very brief summary of the changes between DSM-5 and DSM-IV. As mentioned above, you should look closely at the diagnostic criteria for each client’s diagnosis when you begin using the DSM-5 and also look at the listing of categories and diagnoses to see if there is a new diagnosis that fits your client’s symptoms more closely than a diagnosis which is familiar to you from the DSM-IV.

I hope you found this blog to be a helpful introduction to DSM-5. Please email me with comments, questions or suggestions for future blog topics.

I just started my first practicum placement and I am supposed to give a diagnosis to each client. I’m worried that I don’t have enough experience to make a diagnosis and that my diagnosis might create problems for my clients later on, if they or someone else sees their records.

Your concerns are common among students in practicum training. It often feels daunting to take on the role of assigning a diagnosis to your client. You may be uncomfortable with the gravity of this professional responsibility, and you may have questions about the validity of diagnostic labels that don’t include consideration of the client’s strengths and capacities. Many clinicians are aware of the potential use of diagnosis in pathologizing or stigmatizing individuals who are vulnerable to being treated with discrimination and bias. I will share several steps you can take to maximize the likelihood that your diagnostic process will be beneficial to the client rather than harmful.

The first step is to be thorough and comprehensive in gathering relevant information and considering alternative diagnoses that fit your client’s symptoms and presenting problem. If you are required to assign a preliminary diagnosis after the first session, make sure to re-evaluate the diagnosis after you have completed a full assessment. Be careful of the tendency to jump quickly to a diagnosis that you consider to be non stigmatizing, such as an adjustment disorder, that may not be an accurate reflection of the full clinical picture. I recommend reading the DSM diagnostic criteria for three to five alternative diagnoses as well as the information about differential diagnosis considerations for these diagnoses. Once you have reached a conclusion about the client’s diagnosis, review this with your supervisor to insure that your final diagnosis is the most accurate and appropriate for the client’s presentation. With complex clinical presentations, you may have a primary diagnosis and one or more secondary diagnoses.

A second step to take regarding diagnosis is to include a description of the client’s initial symptoms and presenting issues in the client record, in addition to the diagnosis itself. Usually you will complete an initial assessment which should contain the client’s report and your observations that support the diagnosis. Your progress notes should track the client’s thoughts, affective states and behavior related to the diagnosis and any changes to the diagnosis resulting from new information or progress. This insures that anyone viewing the client’s record at a later date will have a more complete picture of the client’s symptoms and functioning than is conveyed by the diagnosis alone.

A third step to maximize the benefit to the diagnostic process is to discuss the diagnosis with the client. Clinicians are often reluctant to do this because of the worries mentioned in your question. However, a collaborative discussion often results in relief and clarity for the client who may feel confusion, self-criticism and shame about her condition. I generally enter these discussions by summarizing what the client has told me and my observations, then sharing the diagnosis that fits the clinical picture. An example is ” You’ve told me that you don’t enjoy anything, that your sleep and appetite are disrupted and that you feel really down. I’ve noticed that you are pretty harsh in judging yourself and your energy seems low. All of these things are signs of depression, and I believe the diagnosis of major depressive disorder fits what you’re experiencing now.” I then ask the client what her thoughts and reactions are to hearing this and engage in a discussion of any questions or concerns she may have. If there is any indication at that time or later in treatment that the client may want her record to be shared with another party, you can remind her that the diagnosis is part of the record and talk about the implications that may have.

I hope you find these suggestions helpful in making diagnoses with more confidence. Please email me with comments, questions or suggestions for future blog topics.

I just had my first session with a 20-year-old woman who meets the DSM criteria for borderline personality disorder. Her emotions are very labile, her relationship with her boyfriend is unstable and she was fired from her job as a nanny recently because she was often late and had frequent crying spells. I think DBT would be a good treatment for her, but she immigrated from Thailand three months ago and I don’t know whether DBT has been used with Thai Americans.

It’s important to be aware of the importance of culture in choosing a treatment modality, but before addressing that question let’s look at the issue of culture related to diagnosis. This young woman’s recent immigration is the context for her symptoms, which makes an initial diagnosis of adjustment disorder more appropriate than borderline personality disorder. If she came alone to take a job as a nanny, the drastic change in cultures would be exacerbated by a loss of social support and the network of relationships she left behind. If she came with her boyfriend, that relationship would be under tremendous strain as they both adjust to U.S culture. In one session, you don’t have time to gather information about her history and background to know whether these symptoms have been longstanding, as required for a personality disorder diagnosis, or whether they developed around the time of her immigration.

Regarding the question of treatment modality, it is possible she would benefit from learning some of the skills that are part of Dialectical Behavior Therapy (DBT). However, if you begin with a diagnosis of adjustment disorder, the initial focus of treatment will be on learning more about the circumstances of her immigration and her life in Thailand as well as her three months in the U.S. You will also want to learn more about her previous strategies for coping with distress, her interpersonal relationships including the boyfriend, and her educational and work achievements. It would also be advisable to learn more about resources appropriate for recent Thai immigrants as well as to research available mental health providers who are fluent in her native language. It will be important to take a collaborative approach with the client, asking what she feels would be helpful and what steps she wants to take, as you talk with her about different treatment options with you or other providers and social supports that are relevant to her circumstances. Consulting with your supervisor, teachers and colleagues who have knowledge and expertise in clinical issues related to immigration and Thai-American culture will also be valuable.

If the client decides to continue in treatment with you, you can then move to the question of specific treatment goals and interventions. Your consultation and supervision may give you information about interventions shown to be effective with Thai American immigrants, but your client’s responses and preferences about treatment are the best source of guidance. You should be prepared to adapt interventions, like DBT, that were developed for a different cultural group and to pay close attention to the subtleties of the therapeutic relationship to gauge the impact of your interactions.

I hope you find these suggestions helpful in working with an individual or family who has recently immigrated from another country and culture. Please email me with comments, questions or suggestions for future blog topics.